CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover

Defines coverage stance for measurement of biochemical bone turnover markers (serum/urine tests) for diagnosis and management of osteoporosis and conditions with high bone turnover for Blue Cross Blue Shield - Rhode Island commercial and Medicare products, including coding guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Bone Turnover Markers for the Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover

Policy CodePolicy N/A

Change TypeClarified Medicare vs Commercial coverage

Effective DateOct 1, 2015

Next Review Date

Key ActionVerify benefits and contract terms and adjudicate Commercial bone turnover marker tests (e.g., CPT 82523, 83937) as not medically necessary for diagnosis/management of osteoporosis and specified high bone turnover conditions; prior authorization is not required.

SourceLink

POLICY UPDATE CHANGES

BlueCHiP for Medicare covers measurement of bone turnover markers while Commercial Products consider them not medically necessary for diagnosis and management of osteoporosis and certain high bone turnover conditions.

Policy last updated on 06/19/2018 with publication in Provider Updates (Aug 2018, Feb 2017, Aug 2015).

2CPT codes referenced

Not medically necessaryCommercial coverage stance

CoveredBlueCHiP for Medicare stance

Coverage summary

This policy defines a mixed coverage approach to measurement of biochemical bone turnover markers (serum/urine tests): BlueCHiP for Medicare covers measurement of bone turnover markers, whereas for Commercial Products the tests are considered not medically necessary for the diagnosis and management of osteoporosis and for management of conditions with high bone turnover. The scope includes use of commonly reported markers (examples include collagen crosslinks and osteocalcin) as adjuncts to bone mineral density for fracture risk assessment and monitoring treatment response, with coding guidance for CPT codes such as 82523 and 83937.

Policy metadata

Effective Date2015-10-01

Last Review2018-06-19

Policy StatusCURRENT

Coverage Stancemixed (BlueCHiP for Medicare: covered; Commercial: not medically necessary)

Commercial coverage stanceCommercial: Not medically necessary

BlueCHiP for Medicare stanceMedicare: Covered

Medical necessity criteria

BlueCHiP for Medicare

Covered when the following applies:

Measurement of bone turnover markers is covered under BlueCHiP for Medicare (no additional criteria specified).

Medicare coverage is differentiated from commercial coverage as stated in the policy; prior authorization is not required.

Commercial Products - Medical Necessity

Not medically necessary when used for diagnosis or management of osteoporosis or conditions with high bone turnover:

Measurement of bone turnover markers is considered not medically necessary for the diagnosis and management of osteoporosis.

Commercial products consider these tests not medically necessary; relevant CPT codes are listed in coding guidance.

Measurement of bone turnover markers is considered not medically necessary in the management of patients with conditions associated with high rates of bone turnover, including but not limited to Paget disease, primary hyperparathyroidism, and renal osteodystrophy.

Coding guidance

BlueCHiP for Medicare - CPT codes listed as medically necessary (general coding section)CPTCovered

82523	Collagen cross links, any method
83937	Osteocalcin (bone gla protein)

Commercial Products - Commercial guidance: CPT codes not medically necessary when filed with a diagnosis belowCPTNot Covered

82523	Collagen cross links, any method
83937	Osteocalcin (bone gla protein)

Provider actions and billing

Prior Authorization

Prior authorization

Prior authorization review is not required.

Documentation Required

Benefit and contract verification

Benefits may vary between groups and contracts. Please refer to the appropriate Evidence of Coverage or Subscriber Agreement for applicable not medically necessary benefits and coverage determinations.

Billing Rule

Background and evidence

Bone turnover markers are biochemical markers of bone formation or resorption measured in serum and/or urine that have been proposed to supplement bone mineral density (BMD) for fracture risk assessment and to provide earlier assessment of treatment response; however, the evidence is insufficient to show these markers improve patient management, adherence, or health outcomes (for example, reducing fracture rates), and there is uncertainty about their sensitivity to determine individual treatment response.

Evidence summary: systematic reviews and professional position statements conclude there is insufficient evidence that measurement of bone turnover markers improves patient management or clinical outcomes for osteoporosis or other high bone turnover conditions.

Definitions

TermBone turnover markers

DefinitionBiochemical markers of bone formation or bone resorption measured in serum and/or urine (examples include collagen crosslinks and osteocalcin).

Medicare determinations

Name	Number	Effective Date	Type
National Coverage Determination for Collagen Crosslinks, any method	190.19		NCD

Revision history

material_changeLatest

Policy differentiates Medicare coverage from commercial coverage. BlueCHiP for Medicare covers measurement of bone turnover markers while Commercial Products consider them not medically necessary for diagnosis and management of osteoporosis and certain high bone turnover conditions.

06/19/2018update

Policy last updated on 06/19/2018 with publication in Provider Updates (Aug 2018, Feb 2017, Aug 2015).